3: Respiratory System
Approved: 4 Nov 2010. Last amended: 29 Apr 2025.
On this page
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Bronchodilators
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Corticosteroids
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Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors
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Antihistamines, hyposensitisation, and allergic emergencies
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Respiratory stimulants and pulmonary surfactants
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Oxygen
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Mucolytics
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Aromatic inhalations
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Cough preparations
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Systemic nasal decongestants
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Antifibrotics
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Miscellaneous
3.1 Bronchodilators
3.1.1 Adrenoceptor agonists
3.1.1.1 Short-acting beta2 agonists (SABAs)
Recommended
Easyhaler® Salbutamol DPI
(salbutamol)
Alternative
Salbutamol MDI
Prescribe a lower carbon footprint brand e.g. Salamol®
Specific Indication
Salbutamol
nebules
3.1.1.2 Long-Acting Beta2 Agonists (LABAs)
Recommended
EasyHaler® Formoterol DPI
(formoterol)
Alternative
Atimos Modulite® MDI
(formoterol)
3.1.2 Antimuscarinic bronchodilators
3.1.2.1 Short-Acting Muscarinic Antagonists (SAMAs)
Ipratropium MDI
Ipratropium
nebules
3.1.2.2 Long-Acting Muscarinic Antagonists (LAMAs)
Incruse Ellipta® DPI
(umeclidinium)
Spiriva Respimat® SMI
(tiotropium)
3.1.3 Theophylline
Theophylline (Uniphyllin®) m/r
Oral
Aminophylline
Parenteral
3.1.4 Compound bronchodilator preparations
Recommended
Anoro Ellipta® DPI
(umeclidinium 55mcg / vilanterol 22mcg)
Alternative
Bevespi Aerosphere® MDI
(glycopyrronium 7.2mcg / formoterol 5mcg)
Spiolto Respimat® MDI
(tiotropium 2.5mcg / olodaterol 2.5mcg)
3.1.5 Peak flow meters, inhaler devices and nebulisers
3.1.5.1 Peak flow meters
Peak Flow Meter (standard and low range)
3.1.5.2 Drug delivery devices - Spacers
Spacers should be replaced every 12 months but some may need changing at six months.
The spacer should be compatible with the MDI being used.
Spacers should be cleaned monthly. Follow manufacturer's instructions.
Space Chamber Plus
(one piece small volume spacer) – Compatible with most MDI devices
Aero Chamber Plus
(one piece medium volume spacer) – Compatible with most MDI devices
Volumatic
(two piece larger volume spacer) – Compatible with Clenil®, Flixotide®, Salamol®, Seretide®, Serevent®, Ventolin®
3.1.5.3 Sodium Chloride for Nebulisation
Recommended
Sodium chloride 0.9%
Specific Indication
Sodium chloride 7%
Cystic Fibrosis. Specialist use only
3.2 Corticosteroids
3.2.1 General
Prednisolone (oral)
Note: EC preparations are not recommended
Hydrocortisone (IV)
when oral unsuitable
3.2.2 Inhalers
Recommended
Easyhaler® Beclometasone DPI
(beclometasone)
Alternative
Kelhale® MDI
(beclometasone)
Prescribe by brand name: Kelhale® contains ultrafine particles so is 2-2.5 times more potent than standard beclometasone containing inhalers at the same dose)
3.2.3 Compound Preparations
3.2.3.1 Asthma
First choice formulary recommended inhalers for adults (≥18 years):
Recommended
Fobumix Easyhaler® DPI
(budesonide & formoterol)
Enerzair Breezhaler® DPI
(indacaterol 114mcg / glycopyrronium 46mcg / mometasone 136mcg)
Alternative
Luforbec® MDI
(beclometasone & formoterol)
Trimbow® MDI
(beclometasone, formoterol & glycopyrronium)
3.2.3.2 COPD
Recommended
Trelegy Ellipta® DPI
(fluticasone furoate, umeclidinium & vilanterol)
Trimbow® Nexthaler DPI
(beclometasone, formoterol & glycopyrronium)
Alternative
Trimbow® MDI
(beclometasone, formoterol & glycopyrronium)
Trixeo Aerosphere® MDI
(formoterol 5mcg / budesonide 7.2mcg / glycopyrronium 160mcg)
3.3 Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors
3.3.1 Cromoglicate and related therapy
None
3.3.2 Leukotriene receptor antagonists
Recommended
Montelukast
3.3.3 Phosphodiesterase type-4 inhibitors
Roflumilast
COPD, as per NICE TA461
3.4 Antihistamines, hyposensitisation, and allergic emergencies
3.4.1 Antihistamines
3.4.1.1 Non-sedating antihistamines
Recommended
Loratadine
Cetirizine
Fexofenadine
Specific Indication
Rupatadine
4th line for chronic idiopathic urticaria
3.4.1.2 Sedating antihistamines
Recommended
Chlorphenamine
Alternative
Hydroxyzine
Promethazine
3.4.1.3 Allergen immunotherapy
Specific Indication
Benralizumab
Dupilimab
Mepolizumab
Omalizumab
Tezepelumab
Palforzia
Peanut allergy NICE TA769
Reslizumab
as per NICE TA479
Grazax®
Severe grass pollen allergy
Shared Care Guideline
Acarizax®
Severe house dust mite allergy - NICE TA1045
Oralvac Compact®
For allergens where there is no licensed product or there is a combination of allergens
Pharmalgen®
as per NICE TA246
3.4.2 Allergic emergencies
3.4.2.1 Anaphylaxis
Adrenaline
1 in 1,000: IM
Adrenaline (1 in 1,000) 150mcg and 300mcg Auto-Injector for self-administration IM
Training for the specific auto-injector device must be given
Adrenaline
1 in 10,000: slow IV injection reserved for severely ill patients where there is doubt about adequacy of the circulation and absorption from the IM site; with ECG monitoring.
Chlorphenamine
slow IV injection
Hydrocortisone (sodium succinate)
IV
3.4.2.2 Angioedema
Berotralstat
Prevention of recurrent attacks of hereditary angioedema, as per NICE TA738
C1-esterase inhibitor
Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria
Conestat alfa
Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria
Icatibant
Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria
Lanadelumab
Prevention of recurrent attacks of hereditary angioedema, as per NICE TA606
3.5 Respiratory stimulants and pulmonary surfactants
3.5.1 Respiratory stimulants
Doxapram
must be given under expert supervision and combined with active physiotherapy.
Mannitol (Osmohale®)
bronchial provocation test.
3.5.2 Pulmonary surfactants
None
3.6 Oxygen
See oxygen prescription chart and local guidelines
3.7 Mucolytics
Carbocisteine capsules
Consider trial in COPD patients with chronic productive cough (as per NICE guidelines). Stop if no benefit within 4 weeks
Acetylcysteine 600mg effervescent tablets
Use in preference to carbocisteine liquid in patients with swallowing difficulty.
May be used as an alternative to carbocisteine capsules where once daily dosing may aid concordance.
Erdosteine
Acute exacerbation of COPD. Respiratory Consultants only. Max 10 days.
Mannitol (Bronchitol®)
dry powder for inhalation – Cystic Fibrosis as per NICE TA266
3.7.1 Dornase alfa
Dornase alfa
Cystic Fibrosis
3.7.2 Mucous Clearing Devices
Acapella Choice®
On the advice of a Respiratory Physiotherapist
Aerobika®
On the advice of a Respiratory Physiotherapist
3.8 Aromatic inhalations
None
3.9 Cough preparations
3.9.1 Cough suppressants
Recommended
Pholcodine
Morphine
cough in terminal disease
Methadone linctus
Cough in terminal disease. Shared Care Guideline
3.9.2 Demulcent and expectorant cough preparations
Simple linctus
3.10 Systemic nasal decongestants
Systemic nasal decongestants are classified in the BNF as being of limited therapeutic value
3.11 Antifibrotics
Pirfenidone
Idiopathic Pulmonary Fibrosis: NICE TA504
Nintedanib
Idiopathic Pulmonary Fibrosis: NICE TA379
3.12 Miscellaneous
Ivacaftor–tezacaftor–elexacaftor (Kaftrio®)
Cystic fibrosis: NICE TA988
Lumacaftor–ivacaftor (Orkambi®)
Cystic fibrosis: NICE TA988
Tezacaftor–ivacaftor (Symkevi®)
Cystic fibrosis: NICE TA988
On this page
-
Bronchodilators
-
Corticosteroids
-
Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors
-
Antihistamines, hyposensitisation, and allergic emergencies
-
Respiratory stimulants and pulmonary surfactants
-
Oxygen
-
Mucolytics
-
Aromatic inhalations
-
Cough preparations
-
Systemic nasal decongestants
-
Antifibrotics
-
Miscellaneous